16SS1 Case 1 V Paradis Pathology Dpt, Beaujon hospital Clichy, - - PowerPoint PPT Presentation

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16SS1 Case 1 V Paradis Pathology Dpt, Beaujon hospital Clichy, - - PowerPoint PPT Presentation

Aug 31, 2023 322 likes •649 views

16SS1 Case 1 V Paradis Pathology Dpt, Beaujon hospital Clichy, France 43 yearold man Alcohol consumption (50 g/day) for 5 years Presented jaundice and ascitis Liver function tests o PT 35%, AST 105 IU/ml, ALT 52 IU/ml, total

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16‐SS1 Case 1

V Paradis Pathology Dpt, Beaujon hospital Clichy, France

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  • 43 year‐old man
  • Alcohol consumption (50 g/day) for 5 years
  • Presented jaundice and ascitis
  • Liver function tests
  • PT 35%, AST 105 IU/ml, ALT 52 IU/ml, total Bil. 440 µM/l, Alk. P 149

IU/ml, GGT 212 IU/ml

  • Maddrey score (45)
  • Suspicion of cirrhosis with Acute Alcoholic Hepatitis (AAH)
  • Corticoids 40 mg/day for 7 days
  • During treatment, he presented digestive hemorrhage &

Acute renal insufficiency

  • A transjugular biopsy was performed
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20 mm

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Advanced fibrosis (pericellular ++) with Acute Alcoholic Hepatitis (no steatosis)

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  • PT ➘(15%), Creatinin➚
  • AST 107 IU/ml, ALT 133 IU/ml, t.bil 550 µmol/l,

c.bil 370 µmol/l, Alk. P 123 IU/ml, GGT 282 IU/ml

  • MELD 40
  • Liver transplantation (5 days after liver biopsy)
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1800 g

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  • Clinical entity encompassing an acute deterioration of liver

function in patients with underlying chronic liver disease or cirrhosis, which results in failure of one or more organs and high short‐term mortality

☞ Heterogeneity of definition (Up to 13 definitions published) ☞ Prevalence: 25 to 40% of cirrhotic patients admitted to the hospital ☞ Mostly Viral and/or OH chronic liver disease ☞ Triggers: Bacterial infections, OH, Viral relapse, Unknown (20‐45%) ☞ Organ failure (SOFA: Sequential Organ Failure Assessment) : Kidney (56%) > Liver > Coagulation > Brain > Circulation> Lung (9%)

Hernaez R et al Gut 2017 (review)

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  • Aims
  • Characterize the liver histological features in ACLF
  • Investigate whether histological parameters can determine

the prognosis and differentiate end‐stage fibrotic liver disease from ACLF

  • Study whether etiology influences histology–prognosis

relationship

Rastogi A et al Virchows Arch 2011

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Rastogi A et al Virchows Arch 2011

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Rastogi A et al Virchows Arch 2011

LB helpful for (1) Prognostication, (2) Differentiation acute liver failure from acute‐on‐chronic liver failure, (3) providing clues to the underlying etiology (might influence treatment strategy)

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  • Required in settings of
  • Diagnostic uncertainty and/or concurrent liver disease
  • Determine the accurate staging of ALD
  • May help to evaluate the prognosis in alcoholic hepatitis
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  • Assess the value of early liver

biopsy in patients with acute deterioration of alcoholic cirrhosis

  • diagnose ASH
  • grade the severity of ASH
  • determine its prognostic value
  • Liver biopsy performed between

days 1 and 7 of admission

  • Review by 2 pathologists

Mookerjee RP J Hepatol 2011

CK8/CK18

Score 1 2 3 4 5 Ballooned hepatocytes 0% <5% 5‐10% 10‐20% 20‐50% >50% Lobular Infl 0‐1 0‐1 1 1 1‐2 Grade ASH 1 2

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  • Disagreement in >30% of cases
  • ver the definition of hepatocyte

ballooning

  • K8/18 immunostaining, facilitated

mutual agreement by the pathologists on Ballooning item

  • The score loss of K8/18 staining

(indication of ballooning degeneration) was correlated with ASH grading (r = 0.7, p <0.0001)

  • Fibrosis
  • Cirrhosis (75%)
  • Incomplete cirrhosis (16%)
  • Indeterminate cirrhosis (9%)
  • Steatosis
  • No (31%) & Mild (36%)
  • Moderate (17%)
  • Marked (16%)
  • ASH grading system
  • Grade 0 / absent (54%)
  • Grade 1 / mild‐moderate (21%)
  • Grade 2 / severe (25%)

Mookerjee RP J Hepatol 2011

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ASH grade correlated with survival (p<0.001) Mookerjee RP J Hepatol 2011

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Altamirano J Gastro 2014

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Altamirano J Gastro 2014

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16SS1 Case 1 +3 +2 +2 TOTAL 7 52% of survival @ 3 months

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  • 7 centers (2006‐2010)
  • Case control study
  • 26 severe AH failed to

response to therapy (mean Lille model 0.88)

  • 26 matched controls
  • Follow‐up
  • 3 resumed drinking OH
  • @720, 740 and 1140 days

Mathurin P NEJM 2011

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3 years later: ALT 3N, GGT 5N, no metabolic syndrome

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  • ACLF
  • Syndrome characterized by acute and severe hepatic abnormalities in

patients with underlying chronic liver disease or cirrhosis

  • In contrast to decompensated cirrhosis, ACLF has a high short‐term

mortality, mimicking the prognosis of acute liver failure

  • Concerns mostly Viral and/or alcohol chronic liver diseases
  • Liver histology is a good predictor of outcome
  • Stage of fibrosis (>F3), extent of ductular reaction, ballooning, apoptosis

and parenchyma left are independent pronostic factors

  • Alcoholic Liver disease
  • Liver histology is performant for diagnosis and prognosis
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Dead Sea, October 14, 2018